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Benavides N, Spessott WA, Sanmillan ML, Vargas M, Livingston MS, Erickson N, Pozos TC, McCormick ME, Scharrig E, Messinger YH, Giraudo CG. STXBP2-R190C Variant in a Patient With Neonatal Hemophagocytic Lymphohistiocytosis (HLH) and G6PD Deficiency Reveals a Critical Role of STXBP2 Domain 2 on Granule Exocytosis. Front Immunol 2020; 11:545414. [PMID: 33162974 PMCID: PMC7580532 DOI: 10.3389/fimmu.2020.545414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 08/27/2020] [Indexed: 11/18/2022] Open
Abstract
Neonatal hemophagocytic lymphohistiocytosis (HLH) is a medical emergency that can be associated with significant morbidity and mortality. Often these patients present with familial HLH (f-HLH), which is caused by gene mutations interfering with the cytolytic pathway of cytotoxic T-lymphocytes (CTLs) and natural killer cells. Here we describe a male newborn who met the HLH diagnostic criteria, presented with profound cholestasis, and carried a maternally inherited heterozygous mutation in syntaxin-binding protein-2 [STXBP2, c.568C>T (p.Arg190Cys)] in addition to a severe pathogenic variant in glucose 6-phosphate dehydrogenase [G6PD, hemizygous c.1153T>C (Cys385Arg)]. Although mutations in STXBP2 gene are associated with f-HLH type 5, the clinical and biological relevance of the p.Arg190Cys mutation identified in this patient was uncertain. To assess its role in disease pathogenesis, we performed functional assays and biochemical and microscopic studies. We found that p.Arg190Cys mutation did not alter the expression or subcellular localization of STXBP2 or STX11, neither impaired the STXBP2/STX11 interaction. In contrast, forced expression of the mutated protein into normal CTLs strongly inhibited degranulation and reduced the cytolytic activity outcompeting the effect of endogenous wild-type STXBP2. Interestingly, arginine 190 is located in a structurally conserved region of STXBP2 where other f-HLH-5 mutations have been identified. Collectively, data strongly suggest that STXBP2-R190C is a deleterious variant that may act in a dominant-negative manner by probably stabilizing non-productive interactions between STXBP2/STX11 complex and other still unknown factors such as the membrane surface or Munc13-4 protein and thus impairing the release of cytolytic granules. In addition to the contribution of STXBP2-R190C to f-HLH, the accompanied G6PD mutation may have compounded the clinical symptoms; however, the extent by which G6PD deficiency has contributed to HLH in our patient remains unclear.
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Affiliation(s)
- Nathalia Benavides
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
| | - Waldo A Spessott
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
| | - Maria L Sanmillan
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
| | - Marcelo Vargas
- Department of Medical Genetics and Genomics, Children's Minnesota, Minneapolis, MN, United States
| | - Mylynda S Livingston
- Department of Pediatric Hematology-Oncology, Children's Minnesota, Minneapolis, MN, United States
| | - Nissa Erickson
- Minnesota Gastroenterology, P.A., Minneapolis, MN, United States
| | - Tamara C Pozos
- Department of Immunology, Children's Minnesota, Minneapolis, MN, United States
| | - Margaret E McCormick
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
| | - Emilia Scharrig
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
| | - Yoav H Messinger
- Department of Pediatric Hematology-Oncology, Children's Minnesota, Minneapolis, MN, United States
| | - Claudio G Giraudo
- Department of Microbiology and Immunology- Sydney Kimmel Medical College- Thomas Jefferson University, Philadelphia, PA, United States
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Boggs NA, Rao VK. The Role of Bone Marrow Evaluation in Clinical Allergy and Immunology Practice: When and Why. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:3356-3362. [PMID: 32531483 PMCID: PMC10996386 DOI: 10.1016/j.jaip.2020.05.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 11/21/2022]
Abstract
Allergists and immunologists rely on other specialists for higher risk procedures such as biopsies of the lung or gastrointestinal tract. However, we perform and interpret a handful of procedures ourselves. Training programs have historically required competency for prescribing immunoglobulin infusions, patch testing, rhino laryngoscopy, lung function testing, and provocation testing for airway hyperreactivity even though other specialists often perform them. Bone marrow aspirations and biopsies are not included in fellowship training assessments despite a significant number of marrow evaluations being requested by allergists and immunologists. For example, nearly 1 marrow assessment per month has been requested over 2 years for patients in the Allergy Immunology Clinic at Walter Reed National Military Medical Center. Marrow assessments are often required for diagnosis, monitoring, and treatment-related toxicities. Interpretive and procedural competency would benefit the field given the range of diseases in clinical immunology practice that require marrow assessment. We have generated a comprehensive list of the major conditions that might require bone marrow assessments in any Allergy and Immunology practice. We then summarize the specific tests that must be ordered and show how to determine sample quality. Finally, some providers may desire procedural competency and for those individuals we discuss tips for the procedure.
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Affiliation(s)
- Nathan A Boggs
- Uniformed Services University of the Health Sciences, Bethesda, Md.
| | - V Koneti Rao
- National Institutes of Health, National Institute of Allergy and Infectious Diseases, Bethesda, Md
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Okuducu YK, Nwosu A, Awad A, Basak RB. Fever of Unknown Origin in a 17-Year-Old Girl. Cureus 2020; 12:e10607. [PMID: 33133807 PMCID: PMC7586499 DOI: 10.7759/cureus.10607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Fever of unknown origin (FUO) is defined as fever (>101°F) that lasts more than three weeks and for which a cause is not found within seven days of hospital evaluation. FUO has a broad list of differentials - infection, inflammatory diseases, and malignancy. A detailed history and meticulous clinical examination with thorough and stepwise investigations lead to a diagnosis in only two-thirds of cases. In this article, we present a 17-year-old adolescent girl, with no significant past medical history, who presented with FUO during the COVID pandemic. A high index of suspicion and extensive investigations revealed the final diagnosis.
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Clinical profiles and risk factors of 7-day and 30-day mortality among 160 pediatric patients with hemophagocytic lymphohistiocytosis. Orphanet J Rare Dis 2020; 15:229. [PMID: 32867836 PMCID: PMC7456759 DOI: 10.1186/s13023-020-01515-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 08/19/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a relatively rare and life-threatening disorder. Early mortality remains significantly high among patients with HLH. Our aim was to investigate clinical features and risk factors associated with 7-day and 30-day mortality among pediatric HLH patients. We retrospectively collected medical records of patients with discharge diagnosis of HLH between August 2014 and October 2018 from a tertiary children's hospital in China. The main outcome measures were the 7-day and 30-day outcome after hospital admission. The associations between symptoms, concomitant diagnoses, laboratory test results, and the risk of 7-day and 30-day mortality were examined. RESULTS Among 160 pediatric HLH patients, 18 (11.3%) patients were deceased within 7 days after admission, and 46 (28.8%) patients were deceased within 30 days. The identified strong risk factors (OR > 10 and p < 0.05) for 30-day mortality were myocardial damage, severe pneumonia, respiratory failure, coagulopathy, gastrointestinal disorder, and multiple organ dysfunction syndrome (MODS). Factors strongly associated with 7-day mortality were sepsis, myocardial damage, shock, and respiratory failure. All patients deceased within 7 days developed hepatic dysfunction, coagulopathy, and MODS. CONCLUSIONS The identified risk factors could help to stratify patients with high risk of early death, and need to be considered in the development of treatment protocols. As early mortality of HLH remains high, studies are needed to investigate how to initiate adequate HLH-directed treatment strategies for patients at higher risk of early death.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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Almalky MA, Saleh SHA, Baz EG, Fakhr AE. Clinico-laboratory profile and perforin gene mutations of pediatric hemophagocytic lymphohistiocytosis cases: a five-year single center study. Pan Afr Med J 2020; 36:354. [PMID: 33224420 PMCID: PMC7664152 DOI: 10.11604/pamj.2020.36.354.25079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/16/2022] Open
Abstract
Introduction hemophagocytic lymphohistiocytosis (HLH) is an immunological disease characterized by hemophagocytosis of blood cells and proliferation of T-cells and histiocytes in the spleen and bone marrow then infiltration into body organs. Familial HLH (FHL) is a fatal disorder and determining gene mutations is a good guide for predicting the prognosis and choosing treatment options. This study aimed to illustrate the clinical, laboratory characteristics, including perforin gene mutation screening, treatment and survival outcome of pediatric HLH patients. Methods we conducted this cross-sectional study on pediatric patients who were diagnosed with HLH using the revised HLH-2004 criteria, from January 2014 to February 2019 at Zagazig University Children's Hospital, Egypt. We collected demographic, clinical and laboratory data and screened for the presence of mutations in perforin (PRF1) gene by polymerase chain reaction (PCR) amplification. We treated the patients according to HLH-2004 treatment protocol and documented their survival outcome. Results the total number of cases were 18; eight males and ten females, the age range was between three months and 12 years. Of the eight HLH-2004 diagnostic criteria, all patients met at least five criteria. We detected PRF1 gene mutation in 38.9% (7 patients) with nine previously unreported mutations. Sixteen patients (88.9%) received HLH-2004 treatment protocol and the remaining two patients died before initiation of treatment. The overall mortality was 72.2% (13 patients). Conclusion our results increase the awareness of clinical and laboratory characterizations of pediatric HLH patients and the prevalence of PRF1 gene mutations among those patients.
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Affiliation(s)
| | | | - Eman Gamal Baz
- Pediatric Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt
| | - Ahmed Elsadek Fakhr
- Microbiology and Immunology Department, Faculty of Medicine, Zagazig University, Sharkia, Egypt.,Pathology Laboratory and Blood Bank, International Medical Center, Jeddah, Saudi Arabia
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56
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Alehashemi S, Goldbach-Mansky R. Human Autoinflammatory Diseases Mediated by NLRP3-, Pyrin-, NLRP1-, and NLRC4-Inflammasome Dysregulation Updates on Diagnosis, Treatment, and the Respective Roles of IL-1 and IL-18. Front Immunol 2020; 11:1840. [PMID: 32983099 PMCID: PMC7477077 DOI: 10.3389/fimmu.2020.01840] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/08/2020] [Indexed: 12/19/2022] Open
Abstract
Recent research has led to novel findings in inflammasome biology and genetics that altered the diagnosis and management of patients with autoinflammatory syndromes caused by NLRP3-, Pyrin-, NLRP1-, and NLRC4-inflammasomes and spurred the development of novel treatments. The use of next-generation sequencing in clinical practice allows for rapid diagnosis and the detection of somatic mutations that cause autoinflammatory diseases. Clinical differences in patients with NLRP3, pyrin, and NLRP1 inflammasomopathies, and the constitutive elevation of unbound free serum IL-18 that predisposes to the development of macrophage activation syndrome (MAS) in patients with gain-of function mutations in NLRC4 led to the screening and the characterization of novel diseases presenting with constitutively elevated serum IL-18 levels, and start to unravel the biology of "high IL-18 states" that translate into the use of biomarkers that improve diagnosis and monitoring of disease activity and investigations of treatments that target IL-18 and IFN-gamma which promise to improve the management and outcome of these conditions. Lastly, advances in structural modeling by cryo-electron microscopy (cryo-EM) of gasdermin, and of NLRP3- and NLRC4-inflammasome assembly, and the characterization of post-translational modifications (PTM) that regulate inflammasome activation, coupled with high-throughput screening (HTS) of libraries of inflammasome-inhibiting compounds, promise a new generation of treatments for patients with inflammasome-mediated diseases.
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Affiliation(s)
- Sara Alehashemi
- Translational Autoinflammatory Diseases Section (TADS), Laboratory of Clinical Immunology and Microbiology (LCIM), National Institutes of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
| | - Raphaela Goldbach-Mansky
- Translational Autoinflammatory Diseases Section (TADS), Laboratory of Clinical Immunology and Microbiology (LCIM), National Institutes of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Bethesda, MD, United States
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57
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Xu XJ, Tang YM. Dilemmas in diagnosis and management of hemophagocytic lymphohistiocytosis in children. World J Pediatr 2020; 16:333-340. [PMID: 31506890 DOI: 10.1007/s12519-019-00299-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 07/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening entity which is characterized by severe hyperinflammation. Now the HLH-2004 protocol has been widely accepted and clinically used; however, many questions still remain in clinical practice. In this review, we discuss the dilemmas in the diagnosis and treatment of HLH in children. DATA SOURCES Original research for articles and literature reviews published in PubMed was carried out using the key term "hemophagocytic lymphohistiocytosis". RESULTS As the gene sequencing technology progresses, the range of causal mutations and primary HLH has been redefined. The monoallelic variants may contribute to the pathogenesis of the disease. Many conditions without defective cytotoxicity of T or NK cells may lead to HLH, such as primary immunodeficiency (PID) and dysregulated immune activation or proliferation (DIAP). HLH shares overlapping clinical and laboratory characteristics with severe sepsis, but usually the single values are more pronounced in HLH than sepsis. H score is another approach to help the diagnosis of secondary HLH. Specific Th1/Th2 cytokine patterns are very helpful tools to differentiate HLH (reactivation of HLH) from sepsis. Moreover, it also has been used successfully to stratify the therapy intensity. The treatment of HLH should consider underlying diseases, triggers and severity. HLH-94 is recommended for patients who need etoposide-based therapy. CONCLUSIONS Dramatic progress has been made during the past decades in understanding the pathophysiology of HLH. However, diagnosis and treatment of HLH remain with many dilemmas because of the heterogeneous nature of the disease. Better understanding new gene defects and more effective diagnostic approaches and salvage regimens are goals for the future.
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Affiliation(s)
- Xiao-Jun Xu
- Division of Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, Key Laboratory of Reproductive Genetics of Ministry of Education, Zhejiang University, Hangzhou, 310003, China
| | - Yong-Min Tang
- Division of Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, Key Laboratory of Reproductive Genetics of Ministry of Education, Zhejiang University, Hangzhou, 310003, China.
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58
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Merli P, Gentile L, Quagliarella F, Cefalo MG, Strocchio L, Locatelli F, Russo C, Gaspari S. QuantiFERON-TB Gold can help clinicians in the diagnosis of haemophagocytic lymphohistiocytosis. Br J Haematol 2020; 191:e64-e67. [PMID: 32712963 DOI: 10.1111/bjh.17001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Leonarda Gentile
- Mycobacteria Unit, Laboratory Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesco Quagliarella
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Maria Giuseppina Cefalo
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Luisa Strocchio
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy.,Sapienza University of Rome, Rome, Italy
| | - Cristina Russo
- Mycobacteria Unit, Laboratory Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Stefania Gaspari
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, Rome, Italy
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59
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Primary Immunodeficiency: New Approaches in Genetic Diagnosis, and Constructing Targeted Therapies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:839-841. [PMID: 30832894 DOI: 10.1016/j.jaip.2018.12.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
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Gloude NJ, Dandoy CE, Davies SM, Myers KC, Jordan MB, Marsh RA, Kumar A, Bleesing J, Teusink-Cross A, Jodele S. Thinking Beyond HLH: Clinical Features of Patients with Concurrent Presentation of Hemophagocytic Lymphohistiocytosis and Thrombotic Microangiopathy. J Clin Immunol 2020; 40:699-707. [PMID: 32447592 PMCID: PMC7245179 DOI: 10.1007/s10875-020-00789-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune system activation driven mainly by high levels of interferon gamma. The clinical presentation of HLH can have considerable overlap with other inflammatory conditions. We present a cohort of patients with therapy refractory HLH referred to our center who were found to have a simultaneous presentation of complement-mediated thrombotic microangiopathy (TMA). Twenty-three patients had therapy refractory HLH (13 primary, 4 EVB-HLH, 6 HLH without known trigger). Sixteen (69.6%) met high-risk TMA criteria. Renal failure requiring renal replacement therapy, severe hypertension, serositis, and gastrointestinal bleeding were documented only in patients with HLH who had concomitant complement-mediated TMA. Patients with HLH and without TMA required ventilator support mainly due to CNS symptoms, while those with HLH and TMA had respiratory failure predominantly associated with pulmonary hypertension, a known presentation of pulmonary TMA. Ten patients received eculizumab for complement-mediated TMA management while being treated for HLH. All patients who received the complement blocker eculizumab in addition to the interferon gamma blocker emapalumab had complete resolution of their TMA and survived. Our observations suggest co-activation of both interferon and complement pathways as a potential culprit in the evolution of thrombotic microangiopathy in patients with inflammatory disorders like refractory HLH and may offer novel therapeutic approaches for these critically ill patients. TMA should be considered in children with HLH and multi-organ failure, as an early institution of a brief course of complement blocking therapy in addition to HLH-targeted therapy may improve clinical outcomes in these patients.
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Affiliation(s)
- Nicholas J Gloude
- Department of Pediatrics, University of California San Diego, San Diego, USA.,Division of Hematology Oncology, Rady Children's Hospital, San Diego, USA
| | - Christopher E Dandoy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Stella M Davies
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Kasiani C Myers
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Michael B Jordan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Rebecca A Marsh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Ashish Kumar
- Division of Hematology Oncology, Rady Children's Hospital, San Diego, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Jack Bleesing
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA.,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Ashley Teusink-Cross
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Sonata Jodele
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA. .,Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.
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61
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Griffin G, Shenoi S, Hughes GC. Hemophagocytic lymphohistiocytosis: An update on pathogenesis, diagnosis, and therapy. Best Pract Res Clin Rheumatol 2020; 34:101515. [PMID: 32387063 DOI: 10.1016/j.berh.2020.101515] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening state of immune hyperactivation that arises in the setting of genetic mutations and infectious, inflammatory, or neoplastic triggers. Sustained, aberrant activation of cytotoxic CD8+ T cells and resultant inflammatory cytokine release are core pathogenic mechanisms. Key clinical features include high persistent fever, hepatosplenomegaly, blood cytopenia, elevated aminotransferase and ferritin levels, and coagulopathy. HLH is likely under-recognized, and mortality remains high, especially in adults; thus, prompt diagnosis and treatment are essential. Familial forms of HLH are currently treated with chemotherapy as a bridge to hematopoietic stem cell transplantation. HLH occurring in rheumatic disease (macrophage activation syndrome) is treated with glucocorticoids, IL-1 blockade, or cyclosporine A. In other forms of HLH, addressing the underlying trigger is essential. There remains a pressing need for more sensitive, context-specific diagnostic tools. Safer, more effective therapies will arise with improved understanding of the cellular and molecular mechanisms of HLH.
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Affiliation(s)
- Georgia Griffin
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA.
| | - Susan Shenoi
- Division of Rheumatology, Seattle Children's Hospital, Seattle, WA, USA
| | - Grant C Hughes
- Division of Rheumatology, University of Washington, Seattle, WA, USA
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62
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Giemza-Stokłosa J, Islam MA, Kotyla PJ. Hyperferritinaemia: An Iron Sword of Autoimmunity. Curr Pharm Des 2020; 25:2909-2918. [PMID: 31686632 DOI: 10.2174/1381612825666190709202804] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/30/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ferritin is a molecule that plays many roles being the storage for iron, signalling molecule, and modulator of the immune response. METHODS Different electronic databases were searched in a non-systematic way to find out the literature of interest. RESULTS The level of ferritin rises in many inflammatory conditions including autoimmune disorders. However, in four inflammatory diseases (i.e., adult-onset Still's diseases, macrophage activation syndrome, catastrophic antiphospholipid syndrome, and sepsis), high levels of ferritin are observed suggesting it as a remarkable biomarker and pathological involvement in these diseases. Acting as an acute phase reactant, ferritin is also involved in the cytokine-associated modulator of the immune response as well as a regulator of cytokine synthesis and release which are responsible for the inflammatory storm. CONCLUSION This review article presents updated information on the role of ferritin in inflammatory and autoimmune diseases with an emphasis on hyperferritinaemic syndrome.
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Affiliation(s)
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Przemysław J Kotyla
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Faculty in Katowice, Medical University of Silesia, 40-635 Katowice, Poland
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63
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Li X, Yan H, Zhang X, Huang J, Xiang ST, Yao Z, Zang P, Zhu D, Xiao Z, Lu X. Elevated serum myoglobin levels at hospital admission and the risk of early death among patients with hemophagocytic lymphohistiocytosis: evidence from 155 pediatric patients. Ann Hematol 2020; 99:963-971. [PMID: 32221652 DOI: 10.1007/s00277-020-03980-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 03/01/2020] [Indexed: 12/20/2022]
Abstract
Patients with hemophagocytic lymphohistiocytosis (HLH) have high risk of early mortality. The purpose of this study was to test the hypothesis that the elevated level of serum myoglobin among patients with HLH is associated with disease severity and increased risk of mortality. We retrospectively investigated the serum myoglobin levels from 155 pediatric patients diagnosed with HLH in the Hunan Children's Hospital, China. The levels of myoglobin and creatine kinase at hospital admission among non-survivors and survivors were compared. The myoglobin level was dichotomized for the estimation of hazard ratio (HR) for mortality. Patients who died within 7 and 30 days of hospitalization had significantly higher myoglobin levels than did survivors (p < 0.05). The myoglobin level was negatively associated with the days of survival among non-survivors (Spearman correlation coefficient = - 0.29, p = 0.04). An elevated myoglobin level (> 90 ng/mL) was significantly associated with increased mortality (unadjusted HR = 2.66, 95%CI: 1.41, 5.00, p = 0.0024) and persisted after adjusting for age, Epstein-Barr virus infection, admission department, acute kidney injury, myocardial damage, and shock. In conclusion, an elevated serum myoglobin level was associated with increased risk of early death among pediatric patients with HLH, suggesting the potential of myoglobin to be used as a reference indicator for monitoring and managing of HLH.
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Affiliation(s)
- Xun Li
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Haipeng Yan
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Xinping Zhang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Jiaotian Huang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Shi-Ting Xiang
- Pediatrics Research Institute of Hunan Province, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenya Yao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Ping Zang
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Desheng Zhu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China
| | - Zhenghui Xiao
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
| | - Xiulan Lu
- Department of Pediatric Intensive Care Unit, Hunan Children's Hospital, University of South China, Changsha, China.
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64
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Latour S, Fischer A. Signaling pathways involved in the T-cell-mediated immunity against Epstein-Barr virus: Lessons from genetic diseases. Immunol Rev 2020; 291:174-189. [PMID: 31402499 DOI: 10.1111/imr.12791] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/05/2019] [Accepted: 06/10/2019] [Indexed: 12/13/2022]
Abstract
Primary immunodeficiencies (PIDs) provide researchers with unique models to understand in vivo immune responses in general and immunity to infections in particular. In humans, impaired immune control of Epstein-Barr virus (EBV) infection is associated with the occurrence of several different immunopathologic conditions; these include non-malignant and malignant B-cell lymphoproliferative disorders, hemophagocytic lymphohistiocytosis (HLH), a severe inflammatory condition, and a chronic acute EBV infection of T cells. Studies of PIDs associated with a predisposition to develop severe, chronic EBV infections have led to the identification of key components of immunity to EBV - notably the central role of T-cell expansion and its regulation in the pathophysiology of EBV-associated diseases. On one hand, the defective expansion of EBV-specific CD8 T cells results from mutations in genes involved in T-cell activation (such as RASGRP1, MAGT1, and ITK), DNA metabolism (CTPS1) or co-stimulatory pathways (CD70, CD27, and TNFSFR9 (also known as CD137/4-1BB)) leads to impaired elimination of proliferating EBV-infected B cells and the occurrence of lymphoma. On the other hand, protracted T-cell expansion and activation after the defective killing of EBV-infected B cells is caused by genetic defects in the components of the lytic granule exocytosis pathway or in the small adapter protein SH2D1A (also known as SAP), a key activator of T- and NK cell-cytotoxicity. In this setting, the persistence of EBV-infected cells results in HLH, a condition characterized by unleashed T-cell and macrophage activation. Moreover, genetic defects causing selective vulnerability to EBV infection have highlighted the role of co-receptor molecules (CD27, CD137, and SLAM-R) selectively involved in immune responses against infected B cells via specific T-B cell interactions.
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Affiliation(s)
- Sylvain Latour
- Laboratory of Lymphocyte Activation and Susceptibility to EBV infection, Inserm UMR 1163, Paris, France.,University Paris Descartes Sorbonne Paris Cité, Imagine Institut, Paris, France
| | - Alain Fischer
- University Paris Descartes Sorbonne Paris Cité, Imagine Institut, Paris, France.,Department of Pediatric Immunology, Hematology and Rheumatology, Necker-Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France.,Collège de France, Paris, France.,Inserm UMR 1163, Paris, France
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65
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Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening condition associated with hyperinflammation and multiple organ dysfunction. It has many causes, symptoms, and outcomes. Early recognition is critical for treatment. Fever, cytopenias, coagulopathy, and hepatosplenomegaly are hallmark findings. Identifying the trigger event is crucial but challenging because of the varied presentations and infrequent provider experience. Diagnostic features include anemia, thrombocytopenia, neutropenia, elevated ferritin, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis (in bone marrow, spleen, or lymph nodes), low or absent natural killer cells, and elevated soluble interleukin 2 receptor assay. Primary treatment goals are eliminating the underlying trigger and suppressing hyperinflammation with steroids, immunoglobulins, or immunomodulators. Specific treatment includes corticosteroids, etoposide, and antithymocyte globulin followed by hematopoietic stem cell transplantation in patients with refractory or relapsing disease. Prompt immunochemical therapy is essential but often complicated by a high risk of treatment-related morbidity and disease recurrence. Despite these challenges, improvements in diagnostic technology and treatment have enhanced survival.
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Affiliation(s)
- Janice Skinner
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Benedicta Yankey
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Brenda K Shelton
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
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66
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Wu R, Deng X, Hao S, Ma L. Successful treatment of diffuse large B-cell lymphoma with secondary hemophagocytic lymphohistiocytosis by R-CHOP-E regimen: a case report. J Int Med Res 2019; 48:300060519882233. [PMID: 31642356 PMCID: PMC7607752 DOI: 10.1177/0300060519882233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare fatal clinical syndrome characterized by a hyperinflammatory condition caused by aberrantly activated macrophages and cytotoxic T cells, resulting in a cytokine storm and organ impairment. Lymphoma, especially B-cell lymphoma in Japan, is a common trigger of secondary HLH. In China, however, most cases of HLH secondary to lymphoma occur in patients with T-cell/natural killer-cell lymphoma or Hodgkin`s lymphoma; HLH is relatively uncommon in patients with B-cell non-Hodgkin's lymphoma. We herein describe a man with diffuse large B-cell lymphoma (DLBCL) and secondary HLH who was successfully treated by R-CHOP-E chemotherapy. All symptoms resolved and laboratory indications of HLH normalized, and complete remission of the lymphoma was achieved. This rare case highlights not only the possibility of HLH secondary to DLBCL but also the importance of early initiation of R-CHOP-E chemotherapy.
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Affiliation(s)
- Ran Wu
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaohui Deng
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Siguo Hao
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Liyuan Ma
- Department of Hematology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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67
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Chiang SCC, Bleesing JJ, Marsh RA. Current Flow Cytometric Assays for the Screening and Diagnosis of Primary HLH. Front Immunol 2019; 10:1740. [PMID: 31396234 PMCID: PMC6664088 DOI: 10.3389/fimmu.2019.01740] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022] Open
Abstract
Advances in flow cytometry have led to greatly improved primary immunodeficiency (PID) diagnostics. This is due to the fact that patient blood cells in suspension do not require further processing for analysis by flow cytometry, and many PIDs lead to alterations in leukocyte numbers, phenotype, and function. A large portion of current PID assays can be classified as “phenotyping” assays, where absolute numbers, frequencies, and markers are investigated using specific antibodies. Inherent drawbacks of antibody technology are the main limitation to this type of testing. On the other hand, “functional” assays measure cellular responses to certain stimuli. While these latter assays are powerful tools that can be used to detect defects in entire pathways and distinguish variants of significance, it requires samples with robust viability and also skilled processing. In this review, we concentrate on hemophagocytic lymphohistiocytosis (HLH), describing the principles and accuracies of flow cytometric assays that have been proven to assist in the screening diagnosis of primary HLH.
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Affiliation(s)
- Samuel Cern Cher Chiang
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Jack J Bleesing
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Rebecca A Marsh
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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68
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Ricaurte FR, Kewan T, Chadalavada P, Misbah S, Daw H. Hemophagocytic Lymphohistiocytosis Associated with Natural T-cell Leukemia. Cureus 2019; 11:e4107. [PMID: 31058001 PMCID: PMC6476604 DOI: 10.7759/cureus.4107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening syndrome of excessive immune activation. It can be triggered by a variety of events that disrupt immune homeostasis, infection being the most common of them. We report a case of a 36-year-old male diagnosed with HLH associated with natural T-cell leukemia. The purpose of this report is to call attention to the clinical presentation, diagnosis, and treatment of HLH.
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Affiliation(s)
- Frank R Ricaurte
- Hematology and Oncology, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Tariq Kewan
- Internal Medicine, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | | | - Seema Misbah
- Hematology and Oncology, Cleveland Clinic - Fairview Hospital, Cleveland, USA
| | - Hamed Daw
- Hematology and Oncology, Cleveland Clinic - Fairview Hospital, Cleveland, USA
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